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Abstract

Background

A large proportion of the annual 3.3 million neonatal deaths could be averted if there
was a high uptake of basic evidence-based practices. In order to overcome this ‘know-do’
gap, there is an urgent need for in-depth understanding of knowledge translation (KT).
A major factor to consider in the successful translation of knowledge into practice
is the influence of organizational context. A theoretical framework highlighting this
process is Promoting Action on Research Implementation in Health Services (PARIHS).
However, research linked to this framework has almost exclusively been conducted in
high-income countries. Therefore, the objective of this study was to examine the perceived
relevance of the sub-elements of the organizational context cornerstone of the PARIHS
framework, and also whether other factors in the organizational context were perceived
to influence KT in a specific low-income setting.

Methods

This qualitative study was conducted in a district of Uganda, where focus group discussions
and semi-structured interviews were conducted with midwives (n = 18) and managers
(n = 5) within the catchment area of the general hospital. The interview guide was
developed based on the context sub-elements in the PARIHS framework (receptive context,
culture, leadership, and evaluation). Interviews were transcribed verbatim, followed
by directed content analysis of the data.

Results

The sub-elements of organizational context in the PARIHS framework—i.e., receptive context, culture, leadership, and evaluation—also appear to be relevant
in a low-income setting like Uganda, but there are additional factors to consider.
Access to resources, commitment and informal payment, and community involvement were
all perceived to play important roles for successful KT.

Conclusions

In further development of the context assessment tool, assessing factors for successful
implementation of evidence in low-income settings—resources, community involvement,
and commitment and informal payment—should be considered for inclusion. For low-income
settings, resources are of significant importance, and might be considered as a separate
sub-element of the PARIHS framework as a whole.

Keywords:

Background

Translating knowledge into practice has been shown to be a slow and nonlinear process
[1]. The importance of knowledge translation (KT) is its potential to bridge the gap
between what is known and what gets done in practice, also called the ‘know-do’ gap
[2]. One striking example of the global ‘know-do’ gap is the estimate that up to 70%
of neonatal deaths could be averted with higher levels of implementation of basic
and predominately cost-effective evidence-based practices (EBPs) [3,4]. These interventions cover the antepartum, intrapartum, and postpartum period, and
include measures such as immediate breastfeeding, prevention and management of hypothermia,
and kangaroo mother care for low-birthweight newborns. However, research on KT originates
mainly from high-income countries, leaving the settings where 99% of the annual 3.3 million
neonatal deaths occur with scarce empirical knowledge on how to translate evidence
into routine practice [5,6].

In order to understand the effectiveness of KT interventions, efforts should be directed
at considering the influence of contextual factors [7]. There are several theories, models, and frameworks that emphasize the importance
of context in KT, and evidence affirms its importance ([8,9]). The importance of better documentation and understanding of context in low-income
countries has been repeatedly emphasized [10-14]. McCoy et al. [15] claim that lack of sensitivity to context and the socio-political nature of health
systems partly explain the frequent failure to bridge the ‘know-do’ gap. Better mapping
of context has also been found to improve implementation by allowing for strategic
tailoring of implementation strategies [16] and by providing opportunities to interpret findings in KT intervention studies.

The’Promoting Action on Research Implementation in Health Services’ (PARIHS) framework
argues that there are three interacting cornerstones that positively influence KT:
strong evidence, supportive organizational context, and appropriate facilitation [17]. Since the first PARIHS publication in 1998, the framework has been subject to evaluation,
which has provided reasonable evidence for validity of its content and constructs
[18-22]. Presently, the framework is also being evaluated in large-scale studies in both
Europe and Vietnam [23,24]. Furthermore, the framework was recently subjected to systematic critical synthesis
where authors concluded that there is empirical support for the separate cornerstones,
although there is a need for rigorous prospective studies where the framework is used
and evaluated [25]. The extensive use and ongoing evaluation of the framework presented an appropriate
base for the work reported in this paper.

The second PARIHS cornerstone is defined as ‘the environment or setting in which the
proposed change is to be implemented’ and includes four sub-elements: receptive context,
culture, leadership, and evaluation [22]. Receptive context includes structural and resource related aspects of context. The
culture sub-element proposes that organizational cultures that can be described as
‘learning organizations’ are more conductive to change. Culture has both been regarded
as something an organization is as well as something that the organization has. When considering culture as something the organization has, the organization is viewed as comprised of several characteristics that can be isolated,
described and manipulated [26]. Organizational culture, seen from the is perspective, has been described as the ‘glue’ that holds an organization together
and stimulates the employee’s commitment [27]. The authors to the PARIHS framework has described culture as degrees of clarity
in values and beliefs, the level of regard for individuals, the organizational ‘drive’
(task versus learning), the degree of consistency in valuing relationships, teamwork,
power, and authority, and the extent of recognition or reward that is provided [20] or, simply put ‘the way we do things’ [20]. Leadership summarizes the nature of human relationships in the practice context.
Leaders play a key role in creating ‘learning organizations.’ The PARIHS framework
claims that transformational leaders, as opposed to autocratic leaders, have the ability
to challenge individuals in an inspiring and enabling way [20]. Transformational leaders ‘articulate a vision or mission and challenge their followers
by providing a personal example’ and ‘have the ability to commit themselves and allow
others to optimize their skills, abilities, knowledge, and potential’ [28,29]. The last sub-element, evaluation, highlights contexts in which feedback based on
organizational and individual evaluation is performance on a regularly basis. Evaluation
has, in the field of public health been defined as ‘efforts aimed at determining as
systematically and objectively as possible, the effectiveness and impact of health-related
(and other) activities in relation to objectives and taking into account the resources
and facilities that have been deployed in the activities being evaluated’ [30]. Evaluation, according to the PARIHS framework, is primarily comprised of the utilization
of locally derived data [20]. McCormack et al. claim that effective healthcare cultures use evidence gathered from several different
sources to support decisions about performance of individuals and the organization
[20]. Features of context according to the PARIHS framework are elaborated upon in Figure 1[22].

Figure 1.The four sub elements of the ‘context’ cornerstone in the PARIHS framework [[22]].

Recently, three quantitative instruments have been developed to assess context aspects
of the PARIHS framework [31-33]. The Alberta Context Tool consists of eight dimensions: leadership, culture, evaluation,
social capital, formal interactions, informal interactions, structural and electronic
resources, and organizational slack with three separate concepts—staffing, space,
and time [32]. The Organizational Readiness to Change Assessment is developed to asses the whole
PARIHS framework, its context cornerstone is assessed with five dimensions: culture,
leadership, measurement and readiness for change, and resources. Lastly, the Context
Assessment Index includes five constructs: collaborative practice, evidence-informed
practice, respect for persons, practice boundaries, and evaluation. All the three
tools were developed for high-income settings and their psychometric properties are
presently being investigated in several studies. Research based on PARIHS has almost
exclusively been conducted in high-income countries [25], and it is not known whether its cornerstones and sub-elements are also of relevance
for KT in low-income settings, or whether other aspects of context are at play. Therefore,
inspired by the three context tools developed from PARIHS and, as a first step towards
developing an instrument to assess organizational context in low-income settings,
the objective of this study was to examine the perceived relevance of the sub-elements
of the organizational context cornerstone of the PARIHS framework, and whether additional
factors in the organizational context were perceived to influence KT in Uganda.

Methods

Study setting and design

This study was carried out in a district of Uganda with about 20 health centers providing
delivery services, including one general hospital with a bed capacity of about 100.
The hospital has a catchment area beyond the district limits, and serves about 1.5 million
individuals. The majority of people in the district earn their livelihood through
farming. The study was conducted within a larger study with the aim to develop a quantitative
assessment tool regarding context in low- and middle-income settings. The larger study
is conducted within the Research for Improved Child Health network, and efforts similar
to the study reported here are undertaken in Vietnam and Bangladesh; findings from
those studies will be reported elsewhere. This study was carried out in a district
where efforts to improve neonatal health and survival was ongoing, subjecting health
workers, primarily midwives, and managers to change.

Data collection

A semi-structured guide was developed based on the four sub-elements of the context
cornerstone (receptive context, culture, leadership, and evaluation) as suggested
in the PARIHS framework (Figure 1) and inspired by the dimensions within its three developed tools [22,31-33]. Focus group discussions (FGDs) and individual interviews were conducted with midwives
working in different levels of the healthcare services in the district in 2010. Individual
interviews were also conducted with managers, for example, those in charge of health
centers and health service managers at district level. All FGDs and individual interviews
were conducted outside the respondent’s place of work to ensure confidentiality and
allow for an open discussion. FGDs are considered a useful method for exploring new
areas, because the interaction among group members brings out different opinions about
the topic under discussion [34]. It has also been suggested that FGDs are a good data collection technique when discussing
sensitive topics [35]. In this study, the FGDs served well for exploring prevailing perceptions about organizational
context among midwives working at different health centers. However, they were less
helpful when conducted with midwives working within the same unit, because it was
challenging for participants to discuss leadership. Therefore, we conducted individual
interviews with midwives working in the same unit. During the FGDs and interviews,
the interviewers tried to clarify unclear concepts, and summarized the respondents’
statements to ensure clarity. To ensure credibility of our study, we triangulated
methods as described above. Triangulation of methods allowed for the exploration of
different aspects of the study objectives. Respondents were provided with reimbursement
for their transportation costs.

Following a pilot FGD with Ugandan midwives, to ensure comprehensiveness of the guide,
the guide was used in both FGDs and individual interviews (Additional file 1). At the beginning of each session, respondents were asked to think of and briefly
describe how the introduction of new knowledge and change in practice had occurred
in their place of work, and throughout the session try to attach their perceptions
of the relevance of the organizational context to those changes. In relation to the
ongoing intervention to improve neonatal health and survival, several such changes
were brought up during discussions, for example, neonatal resuscitation according
to guidelines, the utilization of incubators, and the introduction of death review
meetings.

Data collection sessions were conducted in English (Uganda’s official language) and
audio-recorded. Sessions lasted 45–110 minutes and were performed by AB and SN. After
each data collection session, AB and SN discussed what had emerged, whether any changes
should be made to the guide, and whether further probes were needed.

Participants

We conducted two FGDs and a total of 10 individual interviews. All respondents were
given written information about the study and agreed to participate. Two FGDs were
conducted: one with six midwives from community health centers and one with midwives
working in the hospital. Sampling for the first FGDs was purposive, whereby respondents
from different parts of the district, working under different conditions in terms
of distance to the district hospital and number of healthcare workers in the unit,
were included. The second FGD included seven conveniently sampled midwives working
in the antenatal clinic at the hospital. The reason for choosing this division was
that the organizational context differed between the primary healthcare units and
the district hospital. Because some aspects of the interview guide, primarily leadership,
were difficult to discuss during the FGDs, the study team opted to continue data collection
by conducting individual interviews with other midwives working in the same unit.

Sampling for individual interviews with midwives and managers employed a purposive
snowballing method [36]. In total, 23 (22 female, 1 male) individuals participated in the study; the mean
age was 39 years (range, 26–55 years), the median years since qualification was eight
(range, 2–34), and the median number of years they had worked in the present place
of work was four (range, 1–30 years) (Table 1). The reason for inviting midwives and managers involved in the provision of maternal
and neonatal health and survival was the fact that there was an ongoing intervention
study in the district from which participants could draw experiences.

Data analysis

Preliminary analysis and discussions were held directly after each FGD and interview
to agree on the level of saturation, that is, when the researcher is no longer hearing
new information and ends data collection. The audio-recorded data were transcribed
verbatim by AB and imported to QSR NVivo 8 software, followed by primarily using directed
content analysis as suggested by Hsieh and Shannon [37]. The goal of a directed content analysis is to validate or conceptually extend a
theoretical framework or theory [37]. This deductive directed approach implied a more structured process compared with
inductive content analysis. Using prior research and existing theory, in this case
the PARIHS framework and publications relating to it [17,18,20-22,25], a thorough reading of the transcripts was followed by identifying and highlighting
key concepts that represented the four sub-elements in the semi-structured guide.
Next, all highlighted passages were coded. Further reading, and employing an inductive
approach, as suggested by Graneheim and Lundman [38], led to the identification of additional factors perceived to impact upon the implementation
process, which could not be categorized within the initial scheme. AB performed the
analysis and findings were then discussed in the research group to reach consensus
with regard to what they reflected. Examples of the analysis process are presented
in Tables 2 and 3. In addition, we discussed our findings with peer de-briefers to provide a fresh
perspective for analysis and critique [39]. In this study, peer de-briefers included two health practitioners and public health
researchers from low-income settings and one Swedish implementation researcher. In
total, we involved three peer de-briefers to question the findings from their separate
perspectives.

Ethics

Ethical approval was obtained from the Makerere University School of Public Health
Review Board and the Uganda National Council of Science and Technology. All respondents
were given written information about the study prior to participation and written
consent was obtained. Voluntary participation and confidentiality were ensured, and
respondents were informed of their right to withdraw from the study at any time. They
were also told that data would be analyzed after being de-identified. Data collection
was undertaken outside of respondents’ working units to ensure confidentiality and
avoid disturbance.

Results

In addition to the PARIHS sub-elements, ‘commitment and informal payment’ emerged
as one additional contextual factor within the inductive analysis. Findings are presented
under the headings of the factors identified in the current study and the four sub-elements
of the PARIHS framework.

Commitment and informal payment

The individual health workers’ commitment to their work was brought up as a major
aspect of how context influences the implementation of new practices. This element
was commonly referred to as ‘loss of morale’ due to scarce resources, low salaries,
little appreciation, a heavy workload, and the presence of informal payment:

‘… Though I know that salary, or money is not a motivator … but if it’s not there
it is a demotivator! … Without proper salary, people come to work for the sake of
being on duty. They end up coming late. They come late and leave early. So, the factor
here is called demotivation. People are demotivated. So, even when you teach them
something new, they are reluctant to take it up.’ [Manager, individual interview]

In individual interviews with midwives and managers, the problem of informal payment
emerged, such as patients having to pay for drugs and services that should be available
for free:

‘We have to get a way of surviving, either sell the service or sell the drugs of the
hospital. Drugs disappear, because we are poor … that is how people are surviving.’
[Manager, individual interview]

Another type of informal payment that interviewees were familiar with occurred during
the employment process. It was described that it was common to pay to get a position.
One issue raised in relation to this practice was that it might not be the person
best suited for the job who was offered the position, but rather the one who paid
the most for it.

Receptive context

When broadly discussing what influenced KT, respondents brought up ‘resources’ as
an issue that influenced both the implementation of new knowledge and healthcare services
overall. In the term ‘resources,’ respondents included human resources, equipment,
drugs and supplies, space, means of transport, and time. As an example, respondents
expressed frustration over their experience of coming back from training to their
place of work and failing to be able to implement new skills due to lack of resources.
A respondent who had recently attended a course in infection prevention and control
highlighted the impact of lack of resources:

‘… that week we had a problem, it started with lack of water, then eventually lack
of soap, we could not sterilize our equipment. We had emergencies. Imagine, how do
you repair a ruptured uterus? Instruments are there but you don’t have linen! You
don’t have linen, sterilized linen. We ended up, however, improvising. But that week
we had a lot of sepsis on the ward. A lot!’ [Manager, individual interview]

Culture

Respondents considered on-the-job learning from peers as one of the most important
ways to acquire knowledge on best practices. Midwives described how this occurred
when they were faced with new challenges and needed help to cope with the situation.
Study participants commonly raised the necessity of good communication and cooperation
among the health workers in the unit. In fact, teamwork was perceived as more important
than many other KT efforts (such as training) in order for new practices to become
routine:

‘One thing that hinders implementation is poor communication among ourselves. If we
are going to implement A, B, C, D, but we’re not cooperating, the thing is not going
to move.’ [Midwife, individual interview]

The intraprofessional teamwork was generally considered as supportive, whereas the
lack of trust and teamwork between different professions was brought up as an obstacle
for providing high-quality care. Respondents also expressed that ‘fear of being accused
of doing wrong’ was overriding the trust in the greater team and its ability to work
out problems. When discussing culture, midwives from the hospital told how lower-level
health workers feared expressing their views in meetings with different cadres of
healthcare providers. Respondents viewed these meetings as components of the organizational
structure that could potentially play a larger role in translating knowledge into
practice, if the culture changed to allow the engagement of all health workers in
discussing service delivery.

Leadership

Midwives working in the hospital saw the leader as ‘one of themselves’ rather than
as superior to them. In contrast, midwives working in lower-level health centers expressed
frustration at working under unclear leadership, stating that the leader was neither
present nor part of the team. The perceived importance of having a capable leader
for KT was clear, whereby the leader was seen as a person that should be part of the
working team and while also acting as a role model. Respondents also believed a good
leader should inspire and support professional development. Leaders in the hospital
were perceived as being physically present and open to inviting staff to participate
in organized continuing medical education meetings. In contrast, midwives working
in lower-level health centers in isolated rural areas were not often invited for short
courses or continuing medical education meetings, and instead relied on their leader
for the provision of new knowledge, which further illuminates the importance of leadership
in that setting.

Although the leader in the hospital unit was seen as part of the team, midwives feared
this higher leadership. The strong hierarchical structure was highlighted as informants
used words like ‘autocratic leadership’ to describe the absence of teamwork for meeting
challenges faced by the organization:

‘… the big man will call you, sometimes when the patient is there with the attendant
and ask, ‘Why haven’t you given treatment? You want this patient to die?!’ These things
are discouraging. You know, an autocratic leadership style? People get demotivated.
They just do something because they fear, they work under pressure, they work under
tension.’ [Manager, individual interview]

Evaluation

The perceived importance of supportive supervision and formal meetings to discuss
how to overcome adverse outcomes was clear. On an individual level, the importance
of supportive supervision by a superior, both as a way of detecting gaps as well as
to directly correct faults, was discussed. At the unit level, midwives perceived that
a functioning system to evaluate the health services provided was crucial—both to
identify existing gaps and to monitor the implementation of new interventions.

One strategy considered to be effective in recognizing ‘know-do’ gaps was the routine
death review meetings with an audit component. In these meetings, team members would
systematically share anything they knew regarding the circumstances of the death of
a patient, followed by discussion of possible avoidable causes or malpractices. Further,
the team tried to come up with solutions to the malpractices identified. This initiative
had recently been introduced with the aim of reducing the maternal and perinatal mortality
in the hospital, and was perceived as a promising way for the unit to identify knowledge
gaps and bring about change. However, although respondents found these meetings useful,
they also expressed the need to improve the quality of meeting documentation in order
to improve the quality of feedback data and the subsequent actions taken on the basis
of such data.

In general, respondents appreciated evaluation at unit level, whereas opinions about
individual evaluation, feedback, and recognition were mixed. Some respondents felt
that individual feedback was important in order to address gaps in their knowledge
and skills. It was also stated that positive feedback given to one person influences
others to ‘aim higher.’ However, others mentioned that recognized high-quality performers
would, out of jealousy, be ‘punished’ by being given an increased workload by colleagues.
To avoid biased appraisals, it was suggested that standards should be developed for
the appraisal procedure. Respondents also asked for tangible criteria towards which
they could strive.

In addition to the evaluation and feedback occurring within the healthcare organization,
respondents also underlined the importance of community and client feedback when asked
how knowledge and practice gaps were identified and why change occurs. In particular,
midwives working in primary healthcare centers brought up community involvement as
a driving force for change. Midwives received continuous feedback from the community
on both negative and positive aspects of the healthcare services. In some communities,
the community chairman was in constant dialogue with the health workers and gave regular
feedback on perceived improvements as well as negative incidents. Community engagement
was described as a growing demand from the community for access to health services
and for improved health services. Furthermore, community members were perceived as
‘inquisitive’ as demonstrated in the following quotation.

"‘So, when you come back and they see no change, they say, ‘Now what type of training
was that? Did they really train her? I think maybe she was not trained well.’ You
see, these community members, they are like that. But if they see a change, say better
care of the newborn, then they appreciate.’ [Midwife, FGD]"

Discussion

The great majority of sub-elements and concepts in the context cornerstone of PARIHS
were found also to be relevant in this low-income setting. There were also additional
factors in the organizational context that were perceived to influence KT, such as
commitment and informal payment and community involvement (Figure 2).

In this study, respondents described commitment as the individual’s devotion to the
organization. The lack of commitment was often brought up as a barrier to KT, because
uncommitted health workers were perceived as less likely to change. Commitment was
at first seen as reflecting ‘low-culture’ where health workers did not share the values
of the organization or as ‘low-receptiveness to change’ as respondents described committed
health workers to be more prone to change. However, because commitment in this study
is reflecting an ‘individual’s devotion to the organization he/she belongs to, we
opted to present it separately following discussions in the research team and with
peer de-briefers. To increase the understanding of organizational context, we believe
commitment needs more attention. We found that the shortage of human resources undermines
commitment, similar to findings by McAuliffe et al., who explored the work environment of mid-level healthcare providers in Malawi [40]. They found that the shortage of human resources correlated with emotional exhaustion,
job dissatisfaction, dissatisfaction with one’s profession, and thinking about leaving
one’s job.

Another factor identified in this study, which partly related to low salary and lack
of commitment, was the existence of informal payment, which Lewis defines as ‘payments
to individual and institutional providers, in kind or in cash, that are made outside
official payment channels or are purchases meant to be covered by the healthcare system’
[41]. Respondents brought up the fact that health workers were selling drugs that should
be available for free to patients, thereby falling short in securing resources for
patients who needed them. Furthermore, health workers had to provide informal payment
to acquire new positions. Similar findings have been reported from many settings,
and informal payments are commonly reported as hindering development in low-income
settings [42,43]. A recent Tanzanian study indicates that health workers create artificial shortages
of drugs and supplies and deliberately lower the quality of service in order to collect
extra payments from patients [44]. The impact of corruption has been reported as influencing the implementation of
health sector reforms, and also as having an additional demoralizing effect on health
workers, thereby having a negative influence on health services in general [45,46]. Informal payment is likely to be a key factor influencing not only routine health
service delivery, but also the implementation of EBP. Thus, we consider that commitment
and informal payment should be part of an assessment tool for low-income settings.

Our study clearly indicated that lack of resources is a hindrance to KT in the current
setting. Resources brought up by respondents referred to available assets that would
enable the functioning of their healthcare units and could be divided into four types:
human resources; space; communication and transport; and medicine, equipment and other
supplies. Availability of resources is also proposed as one component of a receptive
context by the PARIHS team [22]. The PARIHS team claim that the relationship between available resources and implementation
of EBPs is not straightforward, and that increased resources need to be appropriately
allocated and managed in order to influence the implementation process positively.
In addition, the PARIHS team also point out that ‘the focus on resources should not
be at the expense of deeper issues such as relationships, cultures, and ways of working’
[20]. Our findings underline that resources are of major importance in a setting that
is suffering from the lack thereof. Ovretveit et al. [47] suggest that decision makers should investigate those resources that are needed prior
to the implementation of new interventions, in order to avoid trying to implement
strategies that require resources that cannot be mobilized. Such an investigation
also links to the definition of evaluation provided in the public health dictionary
[30] that states that one important reason for evaluating health services is to answer
questions about costs in relation to benefits. While resources are an essential aspect
of healthcare improvement in large parts of the world, we think that ‘resources’ should
be considered as a freestanding sub-element of context in the PARIHS framework when
applied in low-income settings.

The relevance of a supportive culture in order for effective KT to take place was
obvious. Respondents brought up that sharing new knowledge while working was of fundamental
importance, perhaps reflecting the lack of organizational slack, leading to few opportunities
to share knowledge. For the sharing of knowledge to occur, the importance of good
teamwork was emphasized. The current findings further indicate that interdisciplinary
teamwork is important, an element that is underlined by results in other studies as
leading to fewer errors and shorter delays [48-51]. Our findings are also congruent with those of a recent study in Kenya, where the
lack of interdisciplinary teamwork was identified as a barrier to successful implementation
of guidelines [52]. The relevance of formal meetings to discuss the provision of care was evident in
the interviews and has been shown to lead to improved practice elsewhere [53,54]. Also consistent with our findings is the importance of approaching and involving
lower-level health workers in the evaluation and planning of health services [22]. Our findings indicate that the current definition and components of culture according
to the PARIHS framework (as described in Figure 1) are also of relevance in the current setting.

Leadership was perceived as being important for promoting effective KT. In particular,
midwives working in health centers were dependent on their leaders to acquire new
knowledge and were therefore much affected by their absence. In general, respondents
described good leadership for KT in words that could be linked to the concept of transformational
leadership as described in the PARIHS framework [20]. Effective leadership gives rise to clear roles and effective teamwork and organizational
structures [17]. In our study, there was a perceived lack of leadership in rural and isolated health
centers that is likely to have a major negative impact on KT. Absenteeism of leaders
in lower-level health centers is a common phenomenon in many low-income settings,
and falls under the broad term of ‘quiet corruption,’ defined by the World Bank as:
‘when public servants fail to deliver services or inputs that have been paid for by
the government’ [42]. McPake et al. studied absenteeism in Uganda, and found that poor quality of healthcare services
created a downward spiral of underutilization of public health facilities where lower
demand for services led to even lower staff attendance and shorter opening hours [55]. Similar to our findings, Manongi and co-workers found that lack of supervision and
feedback left health workers in lower-level health centers feeling unsupported and
undervalued [56]. In contrast, findings in a Kenyan study [57] suggest that supportive leadership might foster a supportive culture and enable good
working relationships between different types of healthcare providers. In 2007, Snowden
and Boon presented four types of leadership, suited for four types of contexts [58]. Simple systems, being relatively stable with clear cause-and-effect relationships,
are suited for traditional leadership styles in terms of command and control, delegation
of tasks to well defined roles, organized structures, and discrete evaluations. As
systems get more complicated, there is an increased demand for the leaders to rely
on facilitation and empowerment of others [58]. Our findings do indicate that the health system under study is complicated, requiring
leaders that model the openness and reflection needed to communicate the vision of
the organization, providing the support needed to lead others towards it [59]. These leadership qualities reflect transformational leadership as described in the
PARIHS framework [20].

We found that community involvement can work as a driver to allow KT to be part of
an evaluation system. The relevance of such community involvement as a component influencing
the KT process in low-income settings is likely to be high because consumer demand
creates a need for the local health system to improve. There are currently numerous
ongoing trials in low-income settings studying the link between the community and
healthcare providers by evaluating community involvement in the health systems. Such
efforts have proven to be effective in some studies [60-62]. However, changing the behaviour of community members in seeking healthcare is a
slow process. A recent review from the World Bank identified community ownership—that
is, to support communities to take part in, contribute to, and be accountable for
an intervention—as one successful approach to KT [63]. Similarly, Du Mortier and Arpagaus found that involving community members in creating
quality of care indicators helped communities to take ownership of healthcare evaluation
and improvement [64]. Taking these findings into consideration, we suggest community involvement should
also be part of the assessment of organizational context in low-income settings. In
addition to the identified importance of community involvement, formal evaluation
and feedback were also perceived as important in the current study setting. Participants
thought it was important to evaluate healthcare performance in order to initiate change.
In terms of receiving feedback on performance, the findings are in line with the proposed
components of the evaluation sub-element (Figure 1). The PARIHS framework considers evaluation as a monitoring and feedback strategy,
using multiple sources and methods, to improve the provision of healthcare [17]. Coherent with our findings and PARIHS, feedback and recognition of health workers
has previously been shown to influence KT positively [22,63,65,66]. We believe that KT would be further strengthened if the Evaluation cornerstone of
the PARIHS framework clearly included end-users engagement and evaluation of health
services.

There is much evidence to show those interventions that should be implemented in order
to reduce the burden of perinatal mortality and, increasingly, researchers argue that
there is as great need to understand the social and system context as epidemiology
when designing healthcare programmes to improve perinatal health outcomes [67,68]. The World Health Organization (WHO) proposes that the health system is composed
of six interconnected building blocks; governance, information, financing, service
delivery, human resources, and medicines and technologies [69]. Both PARIHS and the WHO health system building blocks enable a structured description
of the health system, thereby going beyond seeing the health system as a ‘black box.’
Our findings identify a number of structures in the local healthcare system relating
to these two theoretical models and could be a point of departure to develop a context
assessment tool. Overall, the findings of our study are similar to those of one conducted
in Kenya [52] that identified ten barriers to the implementation of guidelines, including: poor
communication and teamwork; organizational constraints and limited resources; lack
of recognition and appreciation of good work; absence of perceived benefits linked
to adoption of new practices; and lack of motivation. These similarities, and the
links to findings in other low-income countries, and not least the concordance with
the PARIHS framework, suggest that the factors identified might be of general importance,
and not only of relevance in the currently investigated context.

Methodological considerations

Although we reached saturation amongst the study participants we targeted, one limitation
was the small sample. Because this study is a part of a larger study aimed at developing
a context assessment tool for low- and middle-income settings, additional efforts
of this kind from other settings will generate more insights into the transferability
of these findings. This study explored midwives’ and managers’ perception of organizational
characteristics influencing implementation of new knowledge in their place of work,
that is, the ‘internal context.’ However, the internal context is embedded in a larger
health system that further influences implementation; the ‘outer context’ was, however,
not included in the scope of the current study.

We did not find any differences in the managerial versus midwives’ responses, and
we believe that this merely reflects that the managers are also health workers who
are, and have been, subjected to changes. Areas in which the research group were not
in agreement at first included whether ‘commitment’ should be seen as an ‘individual’
factor, or if it affects the ‘organizational’ in such a way that it should, in fact,
also be included in a future assessment tool. Discussions amongst researchers and
peer de-briefers were undertaken in iterative conference calls and via email and we
finally agreed to present ‘commitment’ as a factor of importance to include in an
organization context assessment tool.

Exploration of an existing framework in a new context was challenging in terms of
how to handle different concepts. Although ‘resources’ is one component of the sub-element
‘receptive context’ in the PARIHS framework, we found that it was of such weight in
this setting that it must be given more attention and definitely not be left out as
seen in some descriptions of the framework [32,33,70]. In a later version of the framework, allocation of resources even appear under the
sub-element ‘culture’ [71]. In order to both take into account how the framework is presented in different ways
but primarily for staying true to our findings, we decided to present ‘resources’
as a stand-alone factor.

Conclusions

Improved understanding of the organizational context will promote KT, not only in
high-income countries, but also in low-income countries. The components of organizational
context as suggested by the PARIHS framework appear also to be relevant in a low-income
setting like Uganda. In addition, resources, commitment and informal payment, and
community involvement should be considered as important components for developing
context assessment tools for low-income settings.

Abbreviations

Competing interests

The authors declare that they have no competing interests.

Authors’ contributions

This study was designed by AB, LW, SP and PW. Data collection and a first review of
findings were performed by AB and SN. Verbatim transcription was undertaken by AB,
who was responsible for the data analysis. The draft manuscript was written by AB
and LW. All authors have read and approved the final manuscript.

Acknowledgements

We wish to thank all respondents in this study. Further, we would like to thank Anna-Berit
Ransjö-Arvidsson for advice during analysis of data and Sida for funding the study.

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